Middle East Respiratory Virus MERS Johnathan Ledbetter MPH

Middle East Respiratory Virus (MERS) Johnathan Ledbetter, MPH

MERS Middle Eastern Respiratory Syndrome Coronavirus aka EMC-Co. V or n. Co. V First known onset: March or April 2012 Total cases*: 971 Total deaths*: 356 (36. 7%) Arabian Peninsula and neighboring countries reporting cases: 9 Countries with travel-associated cases: 14 *As of 02/05/15: http: //www. who. int/csr/disease/coronavirus_infections/mers-5 -february-2015. pdf/

Overview of MERS cases (as of 2/05/15) >85% of cases have been reported from Saudi Arabia Median age: 48 years (range: 9 months to 99 years) 63. 5% male Primary cases are on average older and a larger percentage of them are men than secondary cases Many cases have underlying health conditions Many cases are in healthcare workers All cases have direct or indirect links to countries in/near the Arabian Peninsula Transmission patterns have not changed: Secondary cases still tend to be milder than primary cases No sustained human-to-human transmission Very few instances of household transmission for recent cases No increase in the size or number of observed household clusters

Clusters Household/family/close contact clusters: Saudi Arabia (many clusters), UK, Tunisia, Italy, United Arab Emirates (UAE), Iran, Netherlands, Oman Healthcare settings Jordan (Apr 2012) – 10 were HCWs France – hospital roommates Saudi Arabia Multiple small healthcare clusters Several large hospital-associated clusters in Jeddah and other locations in February to May 2014 UAE Multiple small healthcare clusters Hospital cluster in Abu Dhabi (28 cases) in April 2014 http: //www. who. int/csr/disease/coronavirus_infections/en/

MERS-Related Developments: US and TX

US First Confirmed Case Indiana case US citizen; HCW in Saudi Arabia hospital where MERS patients were treated Timeline April 18: developed low-grade fever April 24: began travel to US April 27: increasing fever, runny nose, cough, SOB April 28: hospitalized May 2: tested positive for MERS-Co. V by PCR May 9: patient discharged from hospital; fully recovered and PCR negative No positive contacts

US Second Confirmed Case Florida case HCW from Saudi Arabia Timeline May 1: began travel to US from Saudi Arabia; symptoms began (muscle aches, fever, chills, slight cough) May 9: hospitalized May 11: tested positive for MERS-Co. V by PCR May 18: patient discharged from hospital; fully recovered and PCR negative No positive contacts Not related to first US confirmed case

MERS PUIs and Conveyance Contacts in Texas –May and June 2014 MERS PUIs 28 reported suspected MERS cases 16 meet PUI case definition Median age: 39. 5 (3 -82 years) 68. 8% were male Conveyance Contacts 20 Texas Residents None became ill 12 had serum specimens collected All specimens were negative

Contact Investigation Timeline The Austin/Travis County Perspective By Heather Cooks-Sinclair, MS Epidemiologist

Objectives To detail the steps involved in contact investigation of a emerging infectious disease. Describe the challenges involved in the contact investigation of a emerging infectious disease.

This just In…. Quickly google CDC and other news venues

Refresh your memory. . . Where is it occurring? How is it transmitted? What are the signs and symptoms? What is the case definition? What specimens should be collected? What form should be submitted? Who qualifies to have specimens tested?

The rest of the day. . . • Answer questions from the worried well. Field calls from area providers with patients who have relatives that recently returned from the Middle East?

A few days later, an email arrives. . . • You have a traveler who was on the flight with a confirmed case. – Will you please interview and collect some specimens so the CDC will have more information about MERS Co. V? While interesting and exciting. . . This lack of information does not help you NOW!

You are now the Expert! (at least to the citizen you are calling) • Review the questionnaire • Review the FAQs • Attempt to think of additional questions (knowing that you will NEVER think of them all) • Making the call – – Expect the caller to be anxious Gather information Coordinate specimen collection Answer questions • This is a dance: Some questions you have the answer to others you won’t It is important to sound confident regardless • Follow up any questions you can’t answer with DSHS • Inform the contact that there may not be answers to all questions in an emerging situation – –

Collect the Specimen • Can we collect the specimen? – Who will be collecting the specimen? – Where will we collect the specimen? – Do we have the needed supplies? – Can we get it to the lab in the needed state? – Can we get it to the lab in the required timeframe? • Will the contact agree to provide a specimen? • Are there consent forms? • Will they be provided results? When?

Finally, the results are received. . . • Report results to contact – What does this mean? – Answer questions • Send copy of their results • Close the investigation

What Contributed to Our Success? Strong relationship with DSHS epidemiologists Central Office Regional Office Trained staff Interviews Specimen collection Needed supplies on hand Local access to the DSHS lab

Challenges Answering questions from worried contacts with very little information. Ensuring we have appropriate specimen collection supplies. Ensuring we have trained staff available to collect specimens.

In Summary The steps involved in contact investigation of a emerging infectious disease. Gather information Interview contacts and field questions Coordinate specimen collection Who, what, where, and when? Provide results and field questions • Challenges (The dance of public health investigator): Gathering data, with little information, while assuring the worried.

MERS Investigation Guidance

Case Investigation Suspected (PUI), Probable and Confirmed Cases Case should be investigated immediately Includes immediate notification to DSHS-EAIDB Determine whether the patient meets suspected, probable or confirmed case definition For suspect and probable cases, collect and ship specimens to the DSHS laboratory or another public health laboratory qualified to perform novel coronavirus testing For confirmed cases, verify lab results and make sure the lab that performed confirmatory testing is a public health lab using CDC approved protocol

Case Investigation Suspected (PUI), Probable and Confirmed Cases Ensure appropriate control measures have been implemented at healthcare facility Complete the novel coronavirus-specific PUI Short Form Completion of a more detailed investigation form may be required for probable/confirmed cases Fax the completed novel coronavirus-specific PUI form to DSHS-EAIDB For suspected cases, case investigations may be entered into NEDSS

Case Investigation Probable/Confirmed Cases Identify close contacts and determine if secondary cases have occurred Inform DSHS EAIDB immediately if case-patient used public transportation while symptomatic Be prepared to enhance respiratory surveillance in the local area Cases should be entered into NEDSS

Suspected Case (PUI) Case Definition A person with the following characteristics should be considered a patient under investigation (PUI): Fever AND pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence) AND EITHER: A history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, OR Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula OR A member of a cluster of patients with severe acute respiratory illness (e. g. , fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-Co. V is being evaluated, in consultation with state and local health departments. OR Fever AND symptoms of respiratory illness (not necessarily pneumonia; e. g. , cough, shortness of breath) AND being in a healthcare facility (as a patient, worker or visitor) within 14 days before symptom onset in a country or territory in or near the Arabian Peninsula in which recent healthcare-associated cases of MERS have been identified OR Fever OR symptoms of respiratory illness (not necessarily pneumonia; e. g. , cough, shortness of breath) AND close contact with a confirmed MERS case while the case was ill.

Probable Case, Confirmed Case and Laboratory Confirmation Definitions Probable: A probable case is a PUI with absent or inconclusive laboratory results for MERS-Co. V infection who is a close contact of a laboratory-confirmed MERSCo. V case. Confirmed: A confirmed case is a person with laboratory confirmation of MERS-Co. V infection Laboratory Confirmation Requires a positive PCR on at least two specific genomic targets or a single positive target with sequencing on a second. Confirmed by CDC’s Lab, public health laboratories using CDC- approved protocols for a specific novel strain or by labs using an FDA -approved test for a specific novel strain Other laboratory confirmation criteria may be defined by

Close Contact Definition Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e. g. , healthcare personnel, household members) while not wearing recommended PPE (i. e. , gowns, gloves, respirator, eye protection); OR b) having direct contact with infectious secretions (e. g. , being coughed on) while not wearing recommended PPE (i. e. , gowns, gloves, respirator, eye protection).

MERS Testing in Texas Clinicians should contact their LHD or DSHS In general, patients must meet PUI criteria for testing to be approved Testing requires epidemiology approval These Texas public health labs can test for MERS-Co. V: DSHS Austin All counties may send specimens Dallas Laboratory Response Network (LRN) lab Counties in the Dallas LRN service area may send specimens: Collin, Dallas, Ellis, Fannin, Grayson, Hunt, Kaufman, Navarro, and Rockwall counties Houston LRN lab Counties in the Houston LRN service area may send specimens: Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Hardin, Harris, Jefferson, Liberty, Matagorda, Montgomery, Orange, San Jacinto, Walker, Waller, and Wharton counties LRN service areas: https: //www. dshs. state. tx. us/lab/epr. LRNcontact. shtm

Specimen Collection Collect appropriate specimens and submit to an approved public health laboratory for testing Lower respiratory specimens preferred!! Also collect NP / OP swabs, serum, and stool Collection guidance: http: //www. cdc. gov/coronavirus/mers/guidelines-clinicalspecimens. html Complete DSHS G-2 V Lab Submission Form Under Section 4. Virology, the “Other” box can be marked Please write in “suspect MERS coronavirus” or “suspect novel coronavirus” x Suspect MERS coronavirus

Close Contacts: Testing, etc. Close contacts of a confirmed case Symptomatic close contacts should be evaluated for MERS- Co. V Community and conveyance contacts may be evaluated Symptomatic contacts should be considered for testing, possibly including serological testing Close contacts of a PUI Clinicians should consult with public health Self-monitor for symptoms for 14 days

Questions? ? ?